5840 East Evans Ave.
Denver, CO 80222
PH: 303-300-6900

ELDER CARE PLANNING CHECKLIST
   
Date:  
Name:  
Social Security Number:  
   
Health and Medical Care
Medicare Number  
Medicaid Number  

Doctors
Name Specialty Address Phone Number
       
       
       
       

Other health care or in-home care providers
Name Address Phone Number
     
     
Dentists:
Name Address Phone Number
     
     
     

Current Medications
Name of Drug Dosage How often Taken
     
     
     
     
     

Legal and Financial Information
Location of important papers and documents:
Will  
Living Will  
Power of Attorney  
Durable Medical Power of Attorney  
Heath Care Proxy  
birth Certificate  
Divorce Decree  
Property Deeds  
Safe Deposit Box  
      Location of Keys  
   
Other Documents
   
   

Sources of Income
Income Monthly Amount:
Social Security  
Retirement/pension  
   

Bank Accounts
Type Name of Bank Account Number
Checking    
Savings    
     

Investments
Type Institution or Broker
Phone Number
Location of Acct Statements
Stocks      
Bonds      
Annuities      
Cert of Deposits (CDs)      
Mutual funds      
IRAs      
Money Market      
Other      
       

Name of Accountant/ Broker /Financial Planner
Name Address Phone Number
     
     

Insurance
Type Company or Agent Location of Policy
Life    
Health    
Medigap    
Disability    
Long Term Care    
Dental    
Homeowners/rental    
Liability    
Automobile    

Funeral/Burial Instructions:
 
 
 
Clergy
 
 

Close Friends/Neighbors
Name Address Phone Number